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1. A client who has a new prosthesis for an above-the-knee amputation of the right leg needs teaching on its use. Which of the following instructions should the nurse include?
- A. Wear the prosthesis for 2 hours at a time
- B. Remove the prosthesis every other day
- C. Apply the prosthesis immediately upon waking each day
- D. Elevate the stump for 24 hours after applying the prosthesis
Correct answer: C
Rationale: The correct instruction is to apply the prosthesis immediately upon waking each day. This helps the client adjust to and maintain mobility. Choice A is incorrect because wearing the prosthesis for only 2 hours at a time may not be sufficient for proper adjustment. Choice B is incorrect as removing the prosthesis every other day is not a standard practice and may hinder the client's mobility. Choice D is incorrect because elevating the stump for 24 hours after applying the prosthesis is unnecessary and not a recommended practice.
2. What are the signs and symptoms of Cushing's syndrome, and how should they be managed?
- A. Weight gain, moon face; administer corticosteroids
- B. Hirsutism and thin extremities; manage with diuretics
- C. Purple striae, muscle weakness; provide dietary counseling
- D. Hypertension and bruising; manage with fluid restriction
Correct answer: A
Rationale: The correct signs and symptoms of Cushing's syndrome are weight gain and a moon face. Corticosteroids are used to manage Cushing's syndrome by reducing the overproduction of cortisol. Choice B is incorrect because hirsutism and thin extremities are not typical signs of Cushing's syndrome. Choice C is incorrect as purple striae and muscle weakness are more characteristic of the syndrome. Choice D is also incorrect as hypertension and bruising are not primary signs of Cushing's syndrome.
3. A nurse is assisting with an in-service about hepatitis A for a group of staff nurses. The nurse should include that hepatitis A is transmitted through which of the following methods?
- A. Airborne droplets
- B. Sexual contact
- C. Contact with contaminated surfaces
- D. Consumption of contaminated food
Correct answer: D
Rationale: The correct answer is D: Consumption of contaminated food. Hepatitis A is primarily transmitted through the ingestion of contaminated food or water. Airborne droplets and sexual contact are not common modes of transmission for hepatitis A. While contact with contaminated surfaces can play a role in the spread of some infections, hepatitis A is not typically transmitted through this route.
4. What is the priority nursing action for a dehydrated client who needs fluids?
- A. Administer antiemetics to prevent vomiting
- B. Monitor electrolyte levels frequently
- C. Administer oral rehydration solutions
- D. Insert an NG tube for fluid administration
Correct answer: B
Rationale: The correct answer is to monitor electrolyte levels frequently. When a client is dehydrated and needs fluids, it is essential to monitor electrolyte levels to prevent complications such as electrolyte imbalances. Administering antiemetics to prevent vomiting (Choice A) may be necessary but is not the priority when addressing dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels takes precedence to ensure proper hydration. Inserting an NG tube for fluid administration (Choice D) is invasive and not typically the first-line approach for managing dehydration.
5. When collecting data from a client with posttraumatic stress disorder (PTSD), which of the following manifestations should the nurse expect?
- A. Amnesia
- B. Hypervigilance
- C. Hallucinations
- D. Severe agitation
Correct answer: B
Rationale: The correct manifestation to expect when collecting data from a client with PTSD is hypervigilance. Hypervigilance refers to increased alertness, which is a common symptom of PTSD. This heightened state of awareness is characterized by an exaggerated startle response, being easily startled, and constantly scanning the environment for potential threats. Amnesia (choice A) is not typically a primary manifestation of PTSD; it is more commonly associated with dissociative disorders. Hallucinations (choice C) involve perceiving things that are not present and are not typically a hallmark symptom of PTSD. Severe agitation (choice D) may occur in individuals with PTSD, but hypervigilance is a more specific and common manifestation associated with this disorder.
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